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During an assessment of the cranial nerves, the nurse finds the following: Asymmetry when the client frowns, uneven lifting of the eyebrows, sagging of the lower eyelids, and an escape of air from the right side when the client puffs their cheeks. This would indicate the dysfunction of which of the cranial nerves?

Motor component of IV (Trochlear)

Motor and sensory components of XI (Accessory)

Motor component of VII (Facial)

Motor component of X (Vagus) and sensory component of XII (Hypoglossal)

Answer and Explanation

The Correct Answer is C

A) Motor component of IV (Trochlear): The trochlear nerve primarily controls the superior oblique muscle of the eye, which is responsible for downward and lateral eye movements. The findings described do not relate to eye movement and therefore do not indicate dysfunction of this nerve.

B) Motor and sensory components of XI (Accessory): The accessory nerve innervates the sternocleidomastoid and trapezius muscles, primarily affecting head rotation and shoulder elevation. The symptoms noted in the assessment do not pertain to these muscle functions, so this option is not correct.

C) Motor component of VII (Facial): The signs of asymmetry in frowning, uneven eyebrow lifting, sagging eyelids, and air escaping when puffing the cheeks are characteristic of dysfunction in the facial nerve (cranial nerve VII). This nerve controls the muscles of facial expression, and impairment would lead to the described asymmetrical movements.

D) Motor component of X (Vagus) and sensory component of XII (Hypoglossal): The vagus nerve affects autonomic functions and some swallowing muscles, while the hypoglossal nerve controls tongue movements. Neither nerve is primarily responsible for the facial expressions described in the assessment findings, making this option incorrect.

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A. Range of motion B. Color C. Fine motor assessment by having client touch each finger to thumb D. Pain assessment E. Pulses intact

Correct Answer is ["B","C","D","E"]

Explanation

A) Range of motion: While assessing range of motion can provide information about joint function, it is not a specific component of a peripheral vascular assessment. This assessment primarily focuses on circulation and vascular integrity rather than mobility.

B) Color: Assessing the color of the upper extremities is essential in a peripheral vascular assessment. Changes in color can indicate issues such as poor circulation, hypoxia, or vascular disease, making it a critical observation.

C) Fine motor assessment by having the client touch each finger to thumb: This assessment evaluates both coordination and dexterity, which can indicate adequate blood flow to the fingers and upper extremities. It helps to assess the functional capacity of the hands in relation to vascular health.

D) Pain assessment: Evaluating for pain in the upper extremities is important, as pain can be a sign of vascular problems, including conditions like peripheral artery disease. It provides insight into the presence of ischemia or other vascular issues.

E) Pulses intact: Assessing the pulses in the upper extremities is a key component of a peripheral vascular assessment. Palpating the radial and brachial pulses helps determine blood flow and vascular function in the arms.

A. Listen for another minute just to be sure B. Contact the physician as this is a surgical emergency. C. Auscultate for another 4 minutes D. Listen posteriorly for enhanced bowel sounds

Correct Answer is C

Explanation

A) Listen for another minute just to be sure: While it is important to confirm findings, simply listening for another minute may not provide enough time to accurately assess bowel sounds, as they can be infrequent or absent in certain conditions.

B) Contact the physician as this is a surgical emergency: Not hearing bowel sounds for a minute is not immediately indicative of a surgical emergency. It’s essential to gather more information before escalating the situation.

C) Auscultate for another 4 minutes: This is the appropriate action, as the nurse should auscultate for a total of 5 minutes (1 minute initially and then 4 more minutes) to adequately assess bowel sounds. This duration allows for the detection of normal, hypoactive, or absent bowel sounds, which can provide critical information about the client’s gastrointestinal function.

D) Listen posteriorly for enhanced bowel sounds: While listening from different positions may sometimes help, the standard practice is to listen for an appropriate duration before changing techniques. Auscultating for a longer period is more clinically relevant in this scenario.

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Correct Answer is ["B","C","D","E"]

Explanation

Correct Answer is C

Explanation

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When conducting a peripheral vascular assessment on the upper extremities of a client, the nurse should include which assessments? Select all that apply

Correct Answer is ["B","C","D","E"]

Explanation

The nurse auscultates the client's abdomen for 1 minute and does not hear anybowel sounds. What should the nurse do next?

Correct Answer is C

Explanation

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